I m m e d i a t e Pl a c e m e n t a n d

Imme diat e L o ad i n g
Surgical Technique and Clinical Pearls

a b,
James Parelli, DMD, MD, MS.Ed , Shelly Abramowicz, DMD, MPH *

KEYWORDS
 Immediate implants  Provisionalization  Abutment

KEY POINTS
 Immediate placement and immediate loading of dental implants is a safe and successful
option for replacement of teeth in newly edentulous areas.
 There are specific conditions in which immediate placement and immediate loading are
not recommended, including bony wall defects, poor bone quality, and acute infection.
 There are multiple techniques that practitioners can choose from when deciding to place
immediate implants with immediate loading, all of which can provide more convenience
for the patient and practitioner.
 Immediate implants can be performed for single-unit restorations in partial edentulism, or
for fixed prostheses in complete edentulism.

Dental implants are the preferable method of rehabilitation of partially or completely

edentulous patients.1,2 Traditionally, implant placement follows a nonloading period
of 3 to 6 months for osseointegration.3,4 However, in recent years, the viability of im-
mediate implant loading has been researched in an attempt to shorten the waiting
period for osseointegration.
Immediate loading is defined as a restoration placed on the endosseous implant
structure within 72 hours of placement.5 Multiple prospective studies and systematic
reviews have shown that immediately loaded implants successfully integrate at least
95% of the time.6–8 This integration depends on several factors: surgical technique,
primary stability of the implant, quality and quantity of available bone, minimal post-
operative occlusal loading, and patient selection. Patients with comorbidities, such
as uncontrolled diabetes, osteoporosis, heavy smoking, immunocompromise, and
malnutrition, may experience delayed healing or poorer outcomes.9,10

The author has nothing to disclose.

a
Department of Surgery, Division of Oral and Maxillofacial Surgery, Emory University, 1365
Clifton Road, Building B, Suite 2300, Atlanta, GA 30322, USA; b Department of Surgery, Division
of Oral and Maxillofacial Surgery, Emory University, 1365 Clifton Road, Building B, Suite 2300,
Atlanta, GA 30322, USA
* Corresponding author.
E-mail address: sabram5@emory.edu

Dent Clin N Am - (2014) -–-

http://dx.doi.org/10.1016/j.cden.2014.10.002 dental.theclinics.com
0011-8532/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
2 Parelli & Abramowicz

Immediate-loading implants are generally versatile and can be used in various loca-
tions and conditions, such as a healed edentulous area, a fresh extraction socket,
posterior maxilla in the area of the maxillary sinus, and a narrow-ridge anterior
mandible. To maximize the potential for success, multiple factors must be must be
considered when treatment planning. In an ideal situation, an implant would be placed
into a well-healed ridge with sufficient bone quantity and quality, in a healthy,
nonsmoking patient. This, unfortunately, is not always the case, and preoperative
planning is paramount for optimizing the outcome. There are specific indications
(Box 1) and contraindications (Box 2) for immediate implant placement.

IMMEDIATE PLACEMENT OF IMPLANTS INTO EXTRACTION SITES

The optimal treatment consists of tooth extraction, immediate implant placement, and
immediate loading. This is ideal because it eliminates the need for a period of edentu-
lism and reduces the steps required to reach the final result. In addition, placement of
an immediate implant allows for preservation of associated hard and soft tissues and
minimizes ridge resorption.11,12 Typically, resorption is more pronounced on the
buccal aspect than the lingual/palatal aspects, resulting in a bony crest that is no
longer on the same level of adjacent teeth. This complicates subsequent implant
placement and restoration and may lead to future bone grafts.13
There are bone preservation and augmentation techniques associated with im-
mediate implant placement: bone grafts using autogenous bone,14 bone substi-
tutes,15–18 or platelet concentrates,19 and guided bone regeneration with membrane
placement.20–23 There are several factors that influence postsurgical hard and soft
tissue remodeling, such as initial reason for extraction (eg, periodontal disease, endo-
perio lesion, root fracture), position of implant within the socket,24 and thickness of
alveolar bone on the facial aspect of the socket.25–28
The timing of placement of implants in extraction sockets is the basis for the current
classification system (Table 1).13 From a patient convenience perspective, type I
immediate implant placement and loading is most desirable. However, studies
show that single implants placed into extraction sockets and loaded immediately
have higher failure rates than those placed into healed extraction sites, particularly
in the maxilla.29,30 Nevertheless, success rates often still exceed 95%.13

SURGICAL TECHNIQUE

Implant placement cannot take place in a sterile environment, but is considered a

clean contaminated procedure. When extracting teeth with the intention of immedi-
ately placing an implant, it is important to extract the tooth as atraumatically as
feasible. The goals of this method are to retain as much bone and adjacent soft tissue
as possible. If the tooth is extracted because of an infection, thorough curettage and

Box 1
Indications for immediate implant placement

1. Traumatic avulsion, reimplantation not possible

2. Nonrestorability of tooth because of caries
3. Tooth malposition
4. Failed endodontic therapy
5. External or internal root resorption
 Immediate Placement and Immediate Loading 3

Box 2
Contraindications for immediate implant placement

1. Bony wall defects (that preclude primary stability)

2. Poor quality of bone
3. Acute infection or periodontitis
4. Aesthetic areas that require hard/soft tissue grafting before implantation
5. Inadequate root trajectory

irrigation of the socket with normal saline should be performed before implant place-
ment. Perioperative and postoperative antibiotics are recommended, although more
quality studies are needed for definitive guidelines.11,31
Following an extraction, implant positioning does not depend on the orientation of
the root socket, but rather on the axial position that allows maximum primary stability
and restorability.11 The remaining periodontal ligament should be removed with a
curette, periotome, or round bur. A round bur should be used to score the appropriate
wall of the socket where the osteotomy will commence. It is important to ensure
copious irrigation while performing the osteotomy to prevent bony tissue damage.
Careful attention should be given to angulation of each drill as they are advanced;
perforation of the thin buccal wall could compromise the success of the implant.
Once the series of drills create the appropriate osteotomies for the implant, the implant
should be seated with a torque of approximately 30 Ncm. However, the torque value
depends on the specific implant’s design, surface treatment, and screw thread geom-
etry.12 Most implants placed in extraction sites have gaps between the implant and the
bone because of the difference in size and shape between the implant body and the
extraction socket. In those situations, a concurrent bone graft can be used (eg, autog-
enous, bovine, porous cancellous particulate allograft).
Whatever restorative option is chosen for the single immediate implant, the “imme-
diate-loading” aspect should be nonfunctional. The restored implant should be out of
occlusion so as to not sustain the force of the opposing dentition for 2 to 3 months.
This allows for maximum potential for successful osseointegration.32,33

PROVISIONALIZATION
Partial Edentulism
There are multiple options for provisionalization of immediate-loading single implants.
Typically, a laboratory fabricates the abutment and provisional restoration preopera-
tively. This reduces the chairside time of the restorative dentist. Preoperative impres-
sions are taken and models fabricated. If the site is already edentulous, an implant

Table 1
Classification of immediate implant placement

Type Description
I Implants placed into sockets immediately after extraction
II Implants placed after soft tissue coverage of the socket (4–8 wk after extraction)
III Implants placed in a socket with clinical or radiographic bone fill (12–16 after
extraction)
IV Implants placed in a completely healed edentulous site (>16 wk after extraction)
4 Parelli & Abramowicz

Fig. 1. (A) Tooth has been extracted and the site grafted with human mineralized bone. A
membrane can be used to hold the graft in position. (B) Four months after the tooth extrac-
tion, the ridge has excellent width. (C) Models are made, and an implant analog is position
with the labial surface of the implant approximately 2 mm palatal to a line drawn from the
labial surface of the adjacent teeth. The internal flat surface of the hex is placed directly
labial. (D) Abutment chosen has a gingival collar height of approximately 2 to 3 mm. The
abutment is prepared vertically with minimal change in the wall parallelism to ensure reten-
tion of the provisional crown. (E) Modified fixed abutment. Note that the flat surface has
not been removed so as to improve provisional crown retention. The parallel walls also pro-
vide retention of the provisional crown. (F) Provisional crown on the abutment. (G) Provi-
sional crown on the model. Note the 0.5-mm gap between adjacent contact points to
allow surgical flexibility and passive seating of the crown. The gingival margin has been pre-
pared to match the gingival margin of the tooth before extraction. (H) After administration
of a local anesthetic, a tissue punch is used in the exact location where the crown will
emerge. (I) After the tissue punch has been used, a small incision is made across the crest
and around the adjacent teeth within the gingival sulcus. Elevation of the periosteum is
limited to the superior aspect of the crest. Vertical incisions are not recommended. (J) Circle
of tissue created with the tissue punch is removed. (K) A round bur is used to create the en-
try hole for the first drill. The round bur sets the position of the implant between the teeth,
in the middle of the crest, and in the appropriate buccal-palatal direction. (L) Implant is
properly positioned according to the prescription from the model. Note that the internal
flat surface of the hex is directly labial. Also note the excellent bone contour over the
area. (M) Abutment previously prepared in the laboratory is passively seated and secured
with a screw. After cotton has been placed, the provisional crown is tried. (N) Provisional
crown is placed in position, and after occlusal clearance has been confirmed, it is cemented
in position with temporary cement. Vertical mattress sutures are used to place the gingival
margin back in the correct position. (From Block MS. Color atlas of dental implant surgery.
3rd edition. Maryland Heights (MO): Saunders, an imprint of Elsevier; 2011. Figure 7.1,
p. 310–2; with permission.)
 Immediate Placement and Immediate Loading 5

Fig. 1. (continued).
6 Parelli & Abramowicz

Fig. 2. (A) Treatment plan for this patient calls for the placement of one implant in the first
molar location with immediate placement of a final, “nonprepable” abutment. Before sur-
gery, the gingival collar height is chosen to match the 2-mm gingival thickness; the interoc-
clusal space allowed an abutment 5 mm tall. (B) Implant site is prepared for an expanded
platform type of implant. (C) Implant is placed level with the crestal bone. A radiofrequency
index of 75 indicates excellent implant stability. (D) Abutment is placed and secured with a
gold screw. The margins of the abutment are predetermined, which allows the transfer to
snap into place. (E) Transfer coping is snapped over the margins of the abutment. (F) Impres-
sion is taken by first placing the less viscous material around the transfer coping (Aquasil;
Dentsply/Caulk, Milford, Delaware). (G) Rim of impression material is placed over the putty,
which has been mixed and placed in an impression tray. (H) After removal of the impression
from the mouth, a protection cap is placed over the abutment to prevent trauma to the pa-
tient’s tongue. (I) Impression with the transfer copings in place. This patient had bilateral
implants placed. (J) Abutment analog snapped into the transfer coping in the impression.
(K) Impression with the analog in place is poured in the laboratory. (L) Provisional crown
can be made using a hollowed denture tooth or a hollow-shell crown. (M) Provisional resto-
ration out of occlusion is positioned within days of implant placement. (From Block MS. Co-
lor atlas of dental implant surgery. 3rd edition. Maryland Heights (MO): Saunders, an
imprint of Elsevier; 2011. Figure 7.4, p. 321–3; with permission.)
 Immediate Placement and Immediate Loading 7

Fig. 2. (continued).
8 Parelli & Abramowicz

analog is placed into the model. The abutment is then prepared, and the laboratory
fabricates the provisional restoration. If a tooth is present at the area to receive the
implant, the tooth on the model is removed, the implant analog placed, and provisional
fabricated. Following implant placement, the abutment and provisional can be placed
and adjusted chairside, respecting the concept of nonfunctional loading (Fig. 1).
Another option is to prepare the abutment and provisional chairside on the same
day as implant placement. After the implant is seated, the abutment is placed with
minimal adjustments by the surgeon or restorative dentist. A hollow shell can be
used for fabrication of the provisional restoration chairside. This reduces preoperative
preparation and laboratory costs, but increases time at chairside.
A third option involves implant and final abutment placement by the surgeon. The
laboratory or restorative dentist then fabricates the provisional. After the implant is
seated, the final abutment is placed and secured with a hand-tightened screw. A
snap-on transfer coping is placed over the abutment, and a closed-tray impression
is taken using less viscous impression material around the transfer coping, and
more viscous impression material in the tray. The impression then has the transfer
coping imbedded in the implant location. An abutment analog is then placed into
the transfer coping, and sent to the laboratory or restorative dentist. In the mouth, a
cap is placed over the abutment to prevent trauma to the tongue (Fig. 2).33

Complete Edentulism
In the completely edentulous patient, nonfunctional loading is difficult because there
are no natural teeth to bear the occlusal load. Instead, it is recommended to splint
the implants to distribute the load. The patient should adhere to a soft diet until
osseointegration, approximately 3 months.11
Rehabilitation of the edentulous mandible has been well-studied and renders pre-
dictable results. Some authors recommend placement of two interforaminal mandib-
ular implants followed by immediate loading with overdentures.12,34–36 In the maxilla,
however, immediate rehabilitation is challenging because of the specific anatomy. The
location of the maxillary sinus and nasal cavity and the fact that the maxilla has thinner
cortical bone and less dense trabecular bone make achieving primary stability more
arduous. To increase success, the surgeon may choose to place additional implants
than may be needed; the surgeon and restorative dentist can then plan to load some
while allowing the other implants to remain unloaded and thereby osseointegrate. If
any of the immediately loaded implants were to fail, the remaining unloaded implants
will be viable because they were given a less stressful environment for osseointegra-
tion. Good results have been reported by loading four to six implants in the maxilla,
and allowing additional implants to osseointegrate.11 However, more longitudinal
studies are needed to assess immediately loaded, implant-supported maxillary pros-
theses in the edentulous patient.35,36

SUMMARY

Dental implants have had tremendous improvement since their initial introduction into
clinical practice. With ongoing advances in implant technology and materials, better
data emerge to allow shorter time between placement and restoration. This allows
the restorative dentist and surgeon to provide improved treatment options to patients.
Most evidence that exists supports the practice of immediately placed (after extrac-
tion) and immediately loaded implants. Additional high-quality studies are still needed
to develop specific guidelines for a standardized approach to immediate
rehabilitation.
 Immediate Placement and Immediate Loading 9

REFERENCES

1. Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated implants

in the treatment of the edentulous jaw. J Int Oral Surg 1981;10:387–416.
2. Kammeyer G, Proussaefs P, Lozada J. Conversion of a complete denture to a
provisional implant-supported, screw-retained fixed prosthesis for immediate
loading of a completely edentulous arch. J Prosthet Dent 2002;87:473–6.
3. Branemark PI, Hansson BO, Adell R, et al. Osseointegrated implants in the treat-
ment of the edentulous jaw. Experience from a 10-year period. Scand J Plast
Reconstr Surg 1977;16:1–132.
4. Branemark PI. Osseointegration and its experimental background. J Prosthet
Dent 1983;50:399–410.
5. Nkenke E, Fenner M. Indications for immediate loading of implants and implant
success. Clin Oral Implants Res 2006;17(Suppl 2):19–34.
6. Strub JR, Jurdzik BA, Tuna T. Prognosis of immediately loaded implants and their
restorations: a systematic literature review. J Oral Rehabil 2012;39:704–17.
7. Banemark PI, Engstrand P, Ohrnell LO, et al. Branemark Novum: a new treatment
concept for rehabilitation of the edentulous mandible. Preliminary results from a
prospective clinical follow-up study. Clin Implant Dent Relat Res 1999;1:2–16.
8. Testori T, Meltzer A, Del Fabbro M, et al. Immediate occlusal loading of Osseotite
implants in the lower edentulous jaw. A multicenter prospective study. Clin Oral
Implants Res 2004;15:278–84.
9. Clarizio LF. Immediate implant loading. In: Fonseca RJ, Barber HD, Matheson JD,
editors. Oral and maxillofacial surgery. St. Louis (MO): Saunders Elsevier; 2009.
p. 511–24 Chapter 31.
10. Goiato MC, Bannwart LC, Pesqueira AA, et al. Immediate loading of overden-
tures: systematic review. Oral Maxillofac Surg 2013;18(3):259–64.
11. Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate
implant placement in extraction sites. J Clin Periodontol 2004;31:820–8.
12. Caneva M, Salata LA, De Souza SS, et al. Influence of implant positioning in
extraction sockets on osseointegration: hisomorphometric analyses in dogs.
Clin Oral Implants Res 2010;21:43–9.
13. Del Fabbro M, Ceresoli V, Taschieri S, et al. Immediate loading of postextraction
Implants in the esthetic area: systematic review of the literature. Clin Implant Dent
Relat Res 2013. [Epub ahead of print].
14. Becker W, Becker BE, Polizzi G, et al. Autogenous bone grafting of defects adja-
cent to implants placed into immediate extraction sockets in patients: a prospec-
tive study. Int J Oral Maxillofac Implants 1994;9:389–96.
15. Artzi Z, Tal H, Dayan D. Porous bovine bone mineral in healing of human extrac-
tion sockets. Part 1: histomorphometric evaluations at 9 months. J Periodontal
2000;71:1015–23.
16. Artzi Z, Tal H, Dayan D. Porous bovine bone mineral in healing of human extrac-
tion sockets: Part 2. Histochemical observations at 9 months. J Periodontol 2001;
72:152–9.
17. Lasella JM, Greenwell H, Miller RL, et al. Ridge preservation with freeze-dried
bone allograft and a collagen membrane compared to extraction alone for
implant site development: a clinical and histologic study in humans.
J Periodontol 2003;74:990–9.
18. Barone A, Aldini NN, Fini M, et al. Xenograft versus extraction alone for ridge
preservation after tooth removal: a clinical and histomorphometric study.
J Periodontol 2008;79:1370–7.
10 Parelli & Abramowicz

19. Rutkowski JL, Johnson DA, Radio NM, et al. Platelet rich plasma to facilitate
wound healing following tooth extraction. J Oral Implantol 2010;36:11–23.
20. Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative approach to
alveolar ridge maintenance following tooth extraction. Report of 10 cases.
J Periodontol 1997;68:563–70.
21. Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in
extraction sockets using bioabsorbable membranes. J Periodontol 1998;69:
1044–9.
22. Lang NP, Lui P, Lau KY, et al. A systematic review on survival and success rates of
implants placed immediately into fresh extraction sockets after at least 1 year.
Clin Oral Implants Res 2012;23(Suppl 5):39–66.
23. Nowzari H, Molayem S, Chiu CH, et al. Cone beam computed tomographic mea-
surement of maxillary central incisors to determine prevalence of facial alveolar
bone width  2mm. Clin Implant Dent Relat Res 2010. http://dx.doi.org/10.
1111/j.1708–8208.2010.00287.x.
24. Braut V, Bornstein MM, Belser U, et al. Thickness of the anterior maxillary facial
bone wall: a retrospective radiographic study using cone beam computed
tomography. Int J Periodontics Restorative Dent 2011;31:125–31.
25. Hammerle CH, Chen ST, Wilson TG Jr. Consensus statements and recommended
clinical procedures regarding the placement of implants in extraction sockets. Int
J Oral Maxillofac Implants 2004;19(Suppl):26–8.
26. Chen ST, Beagle J, Jensen SS, et al. Consensus statements and recommended
clinical procedures regarding surgical techniques. Int J Oral Maxillofac Implants
2009;24(Suppl):272–8.
27. Atieh MA, Payne AGT, Duncan WJ, et al. Immediate restoration/loading of imme-
diately placed single implants: is it an effective bimodal approach? Clin Oral
Implants Res 2009;20:645–59.
28. Testori T, Zuffetti F, Caelli M, et al. Immediate vs conventional loading of post-
extraction implants in the edentulous jaws. Clin Implant Dent Relat Res 2013.
http://dx.doi.org/10.111/cid.12055.
29. Chrcanovic BR, Martins MD, Wennerberg A. Immediate placement of implants
into infected sites: a systematic review. Clin Implant Dent Relat Res 2013.
http://dx.doi.org/10.1111/cid.12098.
30. Kim SJ, Ribeiro ALV, Atlas AM, et al. Resonance frequency analysis as a predictor
of early implant failure in the partially edentulous posterior maxilla following imme-
diate nonfunctional loading or delayed loading with single unit restorations. Clin
Oral Implants Res 2013. http://dx.doi.org/10.1111/clr.12310.
31. Block MS. Immediate provisionalization of implant restorations. Color atlas of
dental implant surgery. 3rd edition. St. Louis (MO): Saunders Elsevier; 2011.
p. 308–55 Chapter 7.
32. Tawse-Smith A, Payne AG, Kumara R, et al. Early loading of unsplinted implants
supporting mandibular overdentures using a one-stage operative procedure with
two different implant systems: a 2-year report. Clin Implant Dent Relat Res 2002;
4:33–42.
33. Turkyilmax I, Tozum TF, Tumer C, et al. A 2-year clinical report of patients treated
with two loading protocols for mandibular overdentures: early versus conven-
tional loading. J Periodontol 2006;77(12):1998–2004.
34. Buttel AE, Gratwohl DA, Sendi P, et al. Immediate loading of two unsplinted
mandibular implants in edentulous patients with an implant-retained overdenture:
an observational study over two years. Schweiz Montasschr Zahnmed 2012;
122(5):392–7.
 Immediate Placement and Immediate Loading 11

35. Glauser R, Ree A, Lundgren A, et al. Immediate occlusal loading of Branemark

implants applied in various jawbone regions: a prospective, 1-year clinical study.
Clin Implant Dent Relat Res 2001;3:204–13.
36. Gallucci GO, Morton D, Weber HP. Loading protocols for dental implants in eden-
tulous patients. Int J Oral Maxillofac Implants 2009;24(Suppl):132–46.